Headache and Neurological Deficits with Cerebrospinal Fluid Lymphocytosis in a Helicopter Pilot

BACKGROUND: The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL syndrome) consists of migraine-like headache episodes with >4 h of hemiparesthesia, dysphasia, and/or hemiparesis plus cerebrospinal fluid lymphocytic pleocytosis. While the rarity of HaNDL syndrome often precludes reassurance of the nature of this syndrome, it has consistently been identified as a benign condition that lasts no longer than 3 mo.

CASE REPORT: In the first week of a viral illness, a 29-yr-old male helicopter pilot experienced acute-onset “stumbling” when walking, “nonsensical speech,” migraine-like headache, scintillating scotomata, and paresthesias of the tongue and bilateral extremities that lasted for 4–6 h. Work-up included lumbar puncture, revealing lymphocytic pleocytosis. A week later, he experienced word-finding difficulty, right-sided numbness/paresthesia, and severe occipital headache lasting 3 h. A third episode with sensory symptoms involving the tongue and right arm and leg occurred for a few hours 25 d after the onset of the first episode. Symptoms resolved spontaneously. A month following initial discharge, he denied symptom recurrence. Repeat lumbar puncture 4 mo later showed resolution of his pleocytosis. He was considered neurologically recovered 3 mo after symptom onset.

DISCUSSION: This patient’s transient episodes were consistent with HaNDL syndrome. His symptom resolution involving three episodes within 25 d reflects the transient nature of this condition. It is critical to recognize HaNDL syndrome as a benign, monophasic disorder that resolves within a maximum of 3 mo so that future pilots with a recent history of HaNDL syndrome may safely and expeditiously return to work.

Wetmore EL, Haddon R, Robertson CE, Cowl CT, Elkhatib WY, Garza I. Headache and neurological deficits with cerebrospinal fluid lymphocytosis in a helicopter pilot. Aerosp Med Hum Perform. 2025; 96(10):936–939.